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Housing and mental health

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DOI: 10.1037/0022-006X.68.3.526 · Source: PubMed

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Journal of Consulting and Clinical Psychology Copyright 2000 by the American Psychological Association, Inc.
2000, Vol. 68, No. 3, 526-530 0022-006X/00/$5.00 DOI: 10.1037//0022-006X.68.3.526

Housing Quality and Mental Health

Gary W. Evans Nancy M. Wells

Cornell University University of Michigan

Hoi-Yan Erica Chan Heidi Saltzman

Cornell University University of Vermont

This study examined the potential link between housing quality and mental health. First, the development
of a psychometrically sound, observer-based instrument to assess physical housing quality in ways
conceptually relevant to psychological health is reported. Then 2 different studies, including a prospec-
tive longitudinal design, demonstrate that physical housing quality predicts mental health. Possible
underlying psychosocial processes for the housing quality-psychological distress link are discussed.

The hypothesis that housing quality affects mental health has construction standards or building codes. Neither of these perspec-
proved difficult to evaluate scientifically. The importance and tives has consciously taken into account environmental qualities
salience of this hypothesis stems from the fact that we spend more conceptually relevant to mental health. In addition to serious
time in the home environment than in any other setting. Therefore, conceptual drawbacks, most extant housing quality indices rely on
if the physical environment is capable of influencing mental respondent's self-report of housing quality, thus rendering associ-
health, housing quality ought to be a prime candidate for research. ations with self-report measures of mental health subject to mono-
Furthermore, throughout much of the world, housing stock is method bias. Third, assessment of mental health in the general
substandard, barely meeting, if at all, minimum requirements for population requires instruments designed to measure nonclinical
shelter and refuge. This is sadly true for upward of 10% of housing symptomatology. Prior research on housing quality and mental
in the United States (U.S. House of Representatives, Committee on health has relied primarily on nonstandardized, author-generated
Appropriations, 1994). measures of mental health or used catastrophic indicators, such as
There are several reasons why it has been difficult to conduct psychiatric case openings.
rigorous, scientific research on housing quality and mental health. The aims of the present study were twofold. First, we endeav-
First, people choose where they live. This makes it difficult to ored to develop an observer-based index of housing quality that is
disentangle the impact of housing quality from personal charac- conceptually relevant to mental health and is built on a sound
teristics (e.g., socioeconomic status [SES] and initial levels of psychometric foundation. Second, we assessed the relations be-
mental health) that could lead to spurious associations between tween housing quality and mental health with a standardized
housing quality and mental health. Second, existing measures of mental health index designed for nonclinical populations. More-
housing quality have been developed within one of two perspec- over, we incorporated improvements in research design that reduce
tives: either to assess threats to public health or in terms of the plausibility of alternative explanations for the hypothesized
relationship between housing quality and mental health.
The primary physical housing variable studied in relation to
Gary W. Evans, Department of Design and Environmental Analysis, mental health has been building height or floor level, with con-
Cornell University; Nancy M. Wells, Department of Architecture and cerns focused on the potentially negative impacts of high-rise
Psychology, University of Michigan; Hoi-Yan Erica Chan, Policy Analysis living on young children and their mothers because of restricted
and Management, Cornell University, Heidi Saltzman, Department of play opportunities and social isolation, respectively (Gifford, in
Psychology, University of Vermont.
press). Although there are some null findings, the preponderance
This research was partially supported by grants from the U.S. Depart-
ment of Agriculture, Hatch, New York (327407); the John D. and Cathe- of data supports an association between high-rise occupancy and
rine T. MacArthur Foundation Network on Socioeconomic Status and elevated symptoms of psychological distress among young chil-
Health; the National Institute of Child Health and Human Development dren (Ineichen & Hooper, 1974; Richman, 1977; Saegert, 1982). In
(1F33 HD08473-01); and the Rackham Graduate School, the Institute for a rare true experiment on housing and mental health, Fanning
Research on Women and Gender, and the Seabury Foundation, University (1967) found that young military wives who had been randomly
of Michigan. assigned to multiple-dwelling units had higher rates of neuroticism
We are grateful to Habitat for Humanity and the many families who than their counterparts assigned to single-family, detached hous-
participated in our research. We also thank Jana Cooperman, Kim English,
ing. Many studies have also linked residing on higher floor levels
Missy Globerman, and Amy Schreier for their assistance with this research.
Correspondence concerning this article should be addressed to Gary W. with social isolation among mothers of preschool-age children
Evans, Department of Design and Environmental Analysis, Cornell Uni- (Gifford, in press).
versity, Ithaca, New York 14853-4401. Electronic mail may be sent to A much smaller number of studies has examined housing struc-
gwel@cornell.edu. tural quality as it relates to mental health. These studies have had
526
 BRIEF REPORTS 527

mixed results (Evans, Wells, & Moch, in press; Freeman, 1984; upstate New York. Nine percent of the sample did not graduate from high
Halpem, 1995). Nearly all suffer from serious methodological school, 31% were high school graduates, 45% had some college, and the
deficiencies (e.g., self-reported housing quality, no SES controls, remaining 15% were college graduates.
or unstandardized assessments of mental health) that render defin- In addition to the cross-sectional, rural sample, a longitudinal, urban
sample (n = 31) was assessed before and after relocation into a residence
itive conclusions impossible. Three studies have used stronger
financed and constructed cooperatively with Habitat for Humanity. All of
research designs to look at the physical quality of housing and the women in the urban sample had at least one child living at home (mean
mental health. Wilner, Wackley, Pinkerton, and Tayback (1962) household size = 4.00 people). The sample was low income (mean
studied a large sample of well-matched, low-income families, half income:needs ratio = 1.10, SD = 0.82) and predominantly African Amer-
of whom resided in slum housing and half of whom relocated to ican (61% vs. 39% White). The participants resided in several metropolitan
better quality public housing. Psychological well-being, social areas in Michigan. Ten percent of the women did not graduate from high
relations with neighbors, and children's school performance all school, 23% were high school graduates, 60% had some college, and 7%
significantly improved in the relocated group in comparison with were college graduates.
the group remaining behind in slum housing. Elton and Packer
(1986) compared mental health among public housing occupants
Procedure
requesting relocation because of dissatisfaction with their current
residence. Half of their sample was randomly placed into new Data on housing quality, psychological distress, and background infor-
public housing and half remained in the old housing. The group mation were collected in home interviews. For the longitudinal, urban
placed into new housing evidenced reduced depression and anxiety sample, data were collected on average 4.5 months prior to relocation to the
symptoms relative to the comparison group. More recently, Halp- newly constructed Habitat for Humanity residence and again 7.3 months
ern (1995) studied residents of public housing, half of whose after the move.
residences had been randomly selected to be renovated. His results Psychological distress was measured with the Demoralization Index of
were similar to Elton and Packer's. the Psychiatric Epidemiology Research Instrument (PERI; Dohrenwend,
Whereas the cross-sectional studies reveal small or mixed re- Shrout, Egri, & Mendelsohn, 1980), a standardized symptom checklist for
nonclinical populations (a = .91). Respondents indicate on a 5-point scale
sults, these three longitudinal studies of housing improvements
ranging from 0 (never) to 4 (very often) whether they have experienced a
consistently indicate modest gains in mental health among those particular symptom (e.g., "felt nervous") in the prior 3 months. The PERI
receiving improved housing. Unfortunately, all three of these has been widely used across ethnically, economically, and geographically
longitudinal studies suffer from shortcomings. First and foremost, diverse samples both in the United States and abroad. The PERI shows
they all confound improvements in housing quality with granting concurrent validity with other measures of psychological health (e.g.,
individual requests for improved housing. That is, in each case, Langner, 1962) and is predictive of eventual psychiatric case openings as
people who were granted their request for better housing were well as help-seeking reports (Catalano & Dooley, 1983).
compared with those who also wanted but did not receive im- Housing quality was assessed by trained raters who evaluated the resi-
proved housing. Second, no measures of housing quality were dence and the immediate neighborhood. A large number of items were
included initially to represent a broad range of potentially salient aspects of
applied in these three studies. Older, poorer quality housing was
housing quality for psychological health. Items came from a variety of
contrasted with newer, improved housing options. There was no sources, including existing housing quality indices (Kasl, Will, White, &
assessment of the degree of housing quality improvement for each Marcuse, 1982; U.S. Department of Commerce, Bureau of Census, Inter-
household and thus no assessment of how the degree of housing University Consortium for Political and Social Research, 1990; Wilner et
quality improvement impacted mental health. al., 1962), the child development literature (Bradley & Caldwell, 1987;
To address these and other methodological and conceptual Wachs & Gruen, 1982), and interviews with Cornell University Co-
shortcomings in research on housing quality and mental health, we operative Extension Housing Specialists. Factor analysis and item-scaling
developed an observer-based housing rating scale using psycho- techniques were used to build the final version of the scale. Three-point
metric scaling procedures. We then applied this housing quality ratings of quality were assessed for items composing six subscales: Struc-
instrument in conjunction with a standardized tool for assessing tural Quality (e.g., "Rate the worst ceiling/wall surface in the room" [0 =
more than 1 square foot (.30 nf) loose or missing, 1 = less than 1 square
psychological distress in nonclinical samples in two heterogeneous
foot (.30 m2) loose or missing, 2 = good]), Privacy (e.g., "Do you have to
samples of households. Furthermore, we controlled for income, walk through the bedroom to get to another room?" [0 = more than one
and one of these studies was longitudinal and accounted for other room, 1 = one other room, 2 = no other rooms]). Indoor Climatic
pre-relocation levels of psychological distress. Conditions (e.g., "Heat has broken down" [0 = once a month or more, 1 =
once in the past three months or last winter, 2 = not in a year]), Hazards
Method (e.g., "Stairs are " [0 = potentially dangerous (e.g., no risers to
individual steps, loose or no handrails, nails sticking out)', 1 = structurally
Participants sound but cracked, discolored, paint peeling', 2 = in good condition}),
Cleanliness/Clutter (e.g., "How much clutter is in the kitchen?" [0 =
Data were collected from two independent samples. Cross-sectional data chaos, 1 = some clutter, 2 = little or none]), and Child Resources (e.g.,
were obtained from women (n = 207) who had at least one child living in "Toys are accessible to the child" [0 = no toys clearly accessible to the
the home (mean household size = 3.21 people). The sample was a mixture child, 1 = in one room, 2 = in more than one room]). Neighborhood
of low- and middle-income families (mean income:needs ratio = 1.69, quality was also evaluated (0 = most houses in immediate neighborhood
SD = 1.27). The income:needs ratio is calculated by dividing household have structural damage or are badly in need of paint, I = a few houses in
income by the federal poverty threshold. Thus, a household income:needs immediate neighborhood have structural damage or are badly in need of
ratio of 1.00 is equivalent to the poverty line. The poverty threshold is a per paint, 2 = no houses in immediate neighborhood have structural damage
capita estimate based on annual adjusted cost of living levels. The sample or are badly in need of paint). Neighborhood quality was assessed primar-
was predominantly White (97%) and resided in rural areas throughout ily for evaluating discriminate validity as described below. Some items
528 BRIEF REPORTS

Table 1
Cross-Sectional, Zero-Order Correlations Between the Housing Quality Instrument and Its
Subscales and the Neighborhood Quality Scale

Measure 1 2 3 4 5 6 7

1. Housing Quality — .65** .54** .61** .71** .48** .26** .09

2. Cleanliness/Clutter — .30** .37** .18* .41** .27** .00
3. Indoor Climatic Conditions — .27** .06 .15* .18* -.10
4. Privacy — .23** .25** .12* .11
5. Hazards — .10 .10 .10
6. Structural Quality — '.18* .18*
7. Child Resources — .13
8. Neighborhood Quality —
*/j<.05. **p<.01.

(e.g., heating) were based on interview data, but whenever possible ob- ranging from 3.45 to 9.53. Items were retained on the basis of
server ratings were used (81 out of 88 items). Because one of the primary factor loadings and item analysis (Cronbach's alpha). The inter-
objectives of this study was to develop a reliable and valid instrument to correlation matrix for the subscales is shown in Table 1.
assess housing quality in psychologically meaningful terms, details on the To assess the ability of the Housing Quality Instrument to
Housing Quality Instrument's psychometric properties are presented in the discriminate among housing of known quality, we had a subset
Results section.
of 34 rural houses independently identified as exceptionally good
or poor in housing quality by raters who had been trained to use the
Results Housing Quality Instrument but had not rated the particular houses
Psychometric Properties of the Housing Quality with the Housing Quality Instrument. We then conducted t tests to
Instrument compare overall housing quality and quality on the Housing Qual-
ity subscales with the cross-sectional data. As can be seen in Table
Reliability. Reliability of the Housing Quality Instrument was 2, with the exception of Indoor Climatic Conditions, all of the
assessed with the cross-sectional data in two ways. First, a measure interior housing subscales discriminated between poor- and high-
of internal consistency, Cronbach's alpha, indicated moderate re- quality houses. As expected, neighborhood quality in these rural
liability (rkk = .78) for the overall instrument. Reliability for the homes was not different between the high- and poor-quality
six Housing Quality subscales (Structural Quality, Privacy, Indoor houses.
Climatic Conditions, Hazards, Cleanliness/Clutter, and Child Re- As a third procedure to examine the validity of the Housing
sources) ranged from .71 to .89. Second, interobserver reliability Quality Instrument, we compared the overall Housing Quality
was estimated by comparing the evaluations of two independent score and the subscale scores before and after residential relocation
raters for 23 randomly selected homes (Ebel r = .72). Subscale in the urban longitudinal sample. As shown in Table 3, all of the
interobserver reliability ratings ranged from .61 to .86. indoor subscales, except for Child Resources, showed
Validity. Construct validity was evaluated in several ways. improvement.
Principal-components factor analysis of the cross-sectional data
with oblique rotation yielded six coherent Housing Quality factors Housing Quality and Mental Health
plus a Neighborhood Quality factor. The latter was developed for
use as an independent scale and for a check on discriminate Cross-sectional and longitudinal data are presented for a low-
validity. The six Housing Quality subscales, consisting of 88 and middle-income, rural sample and for a low-income, urban
items, accounted for 32% of the total variance, with eigenvalues sample participating in the Habitat for Humanity housing program.

Table 2
Cross-Sectional Housing Quality Scores for Predetermined Poor- and High-Quality Houses

Poor-quality High-quality
Measure housing housing K2051
Housing Quality 1.90 2.13 6.46*
Cleanliness/Clutter 1.22 1.53 9.85*
Indoor Climatic Conditions 2.09 2.24 1.60
Privacy 2.22 2.33 3.18*
Hazards 1.42 1.68 5.30*
Structural Quality 2.55 2.89 4.39*
Child Resources 1.06 1.46 5.59*
Neighborhood Quality 0.92 1.03 0.54

**p < .01. *** p < .001.

 BRIEF REPORTS 529

Table 3 was also developed to assess neighborhood quality. The Neigh-

Pre- and Post-Relocation Urban Housing Quality Scores borhood Quality scale was not expected to be highly correlated
with the Housing Quality Instrument or its subscales in the rural
Original New areas studied because there is a large degree of heterogeneity in
Measure residence residence 430)
housing quality within neighborhoods. Very few of the residential
Housing Quality 1.87 2.14 8.96* units we studied in upstate New York are located in predominantly
Cleanliness/Clutter 1.41 1.70 5.02* lower- or middle-class neighborhoods; instead, many houses are
Indoor Climatic Conditions 1.80 2.29 4.33* mixed in among properties ranging dramatically in income and
Privacy 1.39 2.24 9.32*
1.46 2.34*
residential quality. We saw this lack of relationship as discriminate
Hazards 1.30
Structural Quality 2.79 3.00 5.15* validity, which was borne out in several respects. The Neighbor-
Child Resources 1.14 1.10 0.86 hood Quality scale was not correlated with overall housing quality
nor with five out of the six subscales of the Housing Quality
**/> < .01. ***p < .001. Instrument (see Table 1). Furthermore, houses that differed in
overall quality could be significantly differentiated by the Housing
We used regression analyses throughout to maintain the continu- Quality Instrument and its subscales (see Table 2), whereas neigh-
ous nature of the Housing Quality Instrument. Because of our borhood quality was not distinctive across high- and low-quality
focus on mothers' psychological distress, the Child Resources housing units. One subscale, Indoor Climatic Conditions, did not
subscale was not included in the overall Housing Quality Instru- significantly differentiate between high- and low-quality houses.
ment. As indicated above, the Child Resources subscale includes We do not have any explanation for why this was the only subscale
items such as availability of toys, books, and other learning ma- that did not behave as expected.
terials for children. Further evidence for the validity of the Housing Quality Instru-
For the cross-sectional, rural sample of low- and middle-income ment comes from expected changes in housing quality in the
mothers, we regressed PERI scores onto the overall Housing longitudinal, urban sample. The residences of a small group of
Quality Instrument after statistically controlling for the income: women moving from substandard to modest, well-built Habitat for
needs ratio (r = —.39 for the correlation between housing quality Humanity housing were evaluated before and after the move. Five
and the income:needs ratio). After controlling for income, we out of the six Housing Quality subscales, as well as overall housing
found that housing quality was a significant predictor of psycho- quality, changed in the expected direction (see Table 3). The one
logical distress (B = -0.46, SE of B = 0.13), r(204) = 3.55, p < Housing Quality subscale to not change, Child Resources, was not
.001. The increment in R2 after controlling for the incomerneeds expected to shift because the provision of resources for children
ratio was .13. As can be seen in Table 4, as housing quality (toys, books, designated play area, etc.) largely reflects parental
increases, symptoms of psychological distress drop. The zero- efforts to provide for children and not the quality of the house per
order R2 between housing quality and the PERI was .12. The data se. Given the 1-year duration from the previous residence to the
shown in Table 4 are for descriptive purposes only; all of the new Habitat for Humanity housing, we did not expect that mothers
regression analyses maintained the continuous nature of the hous- would suddenly alter their provision of resources targeted for their
ing quality variable. children in their home.
For the longitudinal, urban sample, we used changes in overall The second objective of this research was to evaluate in a more
housing quality (Time 1 — Time 2) as the predictor of Time 2 rigorous manner the hypothesis that housing quality can affect
post-relocation PERI scores in a regression equation, statistically mental health. To do this, we used two different samples in
controlling for pre-relocation PERI scores. Thus, we examined the conjunction with a standardized instrument designed to measure
relation between changes in housing quality and residualized psy- low levels of psychological distress in nonclinical populations.
chological distress. Change in housing quality was significantly Results from both studies converged in support of the hypothesis.
related to psychological health (B = -19.70, SE of B = 7.94), In the cross-sectional comparison of low- and middle-income,
r(27) = 2.48, p < .02. The increment in R2 was .13. Improved White, rural inhabitants, after statistically controlling for income,
housing quality was associated with reduced psychological dis- we found that better quality housing was related to lower levels of
tress. Without controlling for prior PERI scores, we found that the psychological distress. Our cross-sectional findings build on ear-
simple R2, post-relocation, was .09.

Table 4
Discussion
Cross-Sectional Housing Quality Quartiles and
The objectives of this study were to develop a reliable and valid Psychological Distress
instrument to assess housing quality and to use that instrument to
examine the effects of housing quality on mental health. Measures Psychological distress score"

of internal consistency and interobserver agreement indicated that Quartile M SD

the Housing Quality Instrument is a reliable instrument. Validity of
the Housing Quality Instrument was demonstrated in several ways. First 1.30 0.62
Factor analysis yielded six coherent and meaningful subscales that Second 1.16 0.55
Third 0.96 0.42
are moderately intercorrelated (see Table 1). These subscales in- Fourth 0.85 0.46
clude Cleanliness/Clutter, Indoor Climatic Conditions, Privacy,
Hazards, Structural Quality, and Child Resources. A separate scale * Range = 0-4.
530 BRIEF REPORTS

Her work indicating that poorer quality housing can lead to poorer Catalano, R., & Dooley, D. (1983). The health effects of economic insta-
mental health (Evans et al., in press; Freeman, 1984; Halpern, bility: A test of the economic stress hypothesis. Journal of Health and
1995). In a second study, low-income African American and Social Behavior, 24, 46-60.
White women residing in urban areas were assessed before and Dohrenwend, B. P., Shrout, P. E., Egri, G., & Mendelsohn, F. S. (1980).
Nonspecific psychological distress and other dimensions of psychopa-
after moving to better quality housing. Changes in housing quality
thology. Archives of General Psychiatry, 37, 1229-1236.
predicted post-relocation PERI scores after statistically controlling Elton, P., & Packer, J. (1986). A prospective randomized trial of the value
for pre-relocation PERI scores. These longitudinal findings are in of rehousing on the grounds of mental health. Journal of Chronic
accord with prior studies of the impacts of housing improvements Disease, 39, 221-227.
on mental health (Elton & Packer, 1986; Halpern, 1995; Wilner et Evans, G. W. (in press). Environmental stress and health. In A. Baum, T.
al., 1962). Revenson, & J. E. Singer (Eds.), Handbook of health psychology.
The data from the present longitudinal sample provide stronger Mahwah, NJ: Erlbaum.
evidence than prior housing research that improved housing qual- Evans, G. W., & Cohen, S. (1987). Environmental stress. In D. Stokols &
ity can benefit mental health. Most studies of housing quality have I. Altaian (Eds.), Handbook of environmental psychology (pp. 571—
relied on cross-sectional designs with respondent assessments of 610). New York: Wiley.
Evans, G. W., Wells, N. M., & Moch, A. (in press). Habitat et la sante
housing quality and, in some cases, had inadequate controls for
mentale [Housing and mental health). In A. Moch (Ed.), A psychosocial
SES. Unfortunately, the few instances of longitudinal designs
approach to the urban environment. Paris: University of Paris.
confounded housing improvements with receiving or being denied Fanning, D. (1967). Families in flats. British Medical Journal, 4, 382-386.
requests for better housing. In the present longitudinal study, all Freeman, H. L. (1984). Housing. In H. L. Freeman (Ed.), Mental health
the participants received better housing. The degree of housing and the environment (pp. 197-225). London: Churchill Livingstone.
improvement predicted the level of change in psychological dis- Gifford, R. (in press). Satisfaction, health, security, and social relations in
tress. Moreover, this effect occurred after controlling for pre- high rise buildings. In A. Seidel & T. Heath (Eds.), Social effects of the
relocation mental health scores. Short of random assignment to building environment. London: E & FN Spon.
housing, the present design illustrates a more scientifically rigor- Halpern, D. (1995). Mental health and the built environment. London:
ous way to study housing quality and human well-being. As noted Taylor & Francis.
Ineichen, B., & Hooper, D. (1974). Wives' mental health and children's
earlier, one study that was able to use random assignment with a
behavior problems in contrasting residential areas. Social Science and
military sample found that multiple-family, high-rise housing did Medicine, 8, 369-374.
appear to have some negative effects on women's mental health Kasl, S., Will, J., White, M., & Marcuse, P. (1982). Quality of the
(Fanning, 1967). Typically, however, researchers are not able to residential environment and mental health. In A. Baum & J. E. Singer
randomly assign individuals to housing. The use of military sam- (Eds.), Advances in environmental psychology (pp. 1-30). Hillsdale, NJ:
ples is not particularly desirable for studying housing quality Erlbaum.
because, generally, the physical quality of military housing is high Langner, T. (1962). A twenty-two item screening score of psychiatric
and relatively homogenous. symptoms indicating impairment. Journal of Health and Social Behav-
Demonstrating that housing quality can be accurately assessed ior, 3, 269-276.
and then shown to predict psychological distress is but a first step Richman, N. (1977). Behavior problems in pre-school children: Family and
social factors. British Journal of Psychiatry, 131, 523-527.
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Saegert, S. (1982). Environment and children's mental health: Residential
important, but at present unanswerable, question is, How does
density and low income children. In A. Baum & J. E. Singer (Eds.),
housing quality affect mental health? What individual and inter- Handbook of psychology and health (pp. 247-271). Hillsdale, NJ: Erl-
personal processes are disrupted by poor housing quality that could baum.
mediate the apparent connection between housing quality and U.S. Department of Commerce, Bureau of Census, Inter-University Con-
psychological distress? We know from research on environmental sortium for Political and Social Research. (1990). U.S. Annual Housing
stressors that individuals chronically exposed to residential crowd- Survey: National core and supplemental file. Washington, DC: U.S.
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priation hearing for 1995 (Pt. 7). Washington, DC: U.S. Government
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Printing Office.
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housing quality could be capable of injuring self-esteem, reflecting ment. New York: Plenum.
on one's status and level of achievement vis-a-vis the outside Wilner, D., Wackley, R., Pinkerton, T., & Tayback, M. (1962). The
world. Additional research is required to further understand how housing environment and family life. Baltimore: Johns Hopkins Univer-
and why housing quality can influence mental health. sity Press.

References Received April 5, 1999

Bradley, R. H., & Caldwell, B. (1987). Early environment and cognitive Revision received August 25, 1999
competence. Early Child Development and Care, 27, 307-341. Accepted September 7, 1999

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